Helping seniors preserve health and financial security for themselves and their loved ones.

Friday, September 18, 2015

Details of Change to Managed Care for Medicaid LTSS

In February 2015, Pennsylvania Governor Wolf directed the
Departments of Human Services (DHS) and Aging to develop a plan to shift Pennsylvania’s method of administering Medicaid
Long Term Services and Supports (LTSS) to a managed care model. This means that
the Pennsylvania will soon begin to hire private insurers (managed care
organizations or “MCOs”) to administer the state’s Medicaid funded long term
care services.

Medicaid is a federal and state
funded benefit program which can pay for the cost of nursing home care and
other long term care services if level of care and financial requirements are
met. Medicaid is a primary source of public funding of nursing home and other
long term care services for older adults.

On September 16th the Commonwealth issued a “Concept
Paper” which describes the features of the new managed care approach – to be
called “Community HealthChoices” (CHC). The plan represents a significant
change that will impact an estimated
450,000 Pennsylvanians including 130,000 older persons and adults with physical
disabilities who are currently receiving LTSS in the community and in nursing
facilities. It is hoped that the managed care approach will result in reduced long
term care costs while adding coordination to the current fragmented system and
allowing more participants to receive services in more independent home and
community based (HCBS) settings.

The new program will roll out in
three phases over three years, beginning in January 2017.

The Concept Paper states the goals of CHC as follows:

1. Enhance opportunities for community-based living. There
will be improved person-centered service planning and, as more community-based
living options become available, the ability to honor participant preferences
to live and work in the community will expand. Performance incentives built
into the program’s quality oversight and payment policies will stimulate a
wider and deeper array of HCBS options.

2. Strengthen coordination of LTSS and other types of
health care, including all Medicare and Medicaid services for dual eligible
individuals. Better coordination of Medicare and Medicaid health services
and LTSS will make the system easier to use and will result in better quality
of life, health, safety and well-being.

3. Enhance quality and accountability. CHC-MCOs will
be accountable for outcomes for the target population, responsible for the
overall health and long-term support for the whole person. Quality of life and
quality of care will be measured and published, giving participants the
information they need to make informed decisions.

4. Advance program innovation. Greater creativity and
innovation afforded in the program will help to increase community housing
options, enhance the LTSS direct care workforce, expand the use of technology,
and expand employment among participants who have employment goals.

5. Increase efficiency and effectiveness. The program
will increase the efficiency of health care and LTSS by reducing preventable
admissions to hospitals, emergency departments, nursing facilities and other
high-cost services, and by increasing the use of health promotion, primary care
and HCBS.

The CHC population will include the following:

Adults
age 21 or older who require Medicaid LTSS (whether in the community or in
private or county nursing facilities) because they need the level of care
provided by a nursing facility or an intermediate care facility for individuals
with other related conditions (ICF/ORC);

Current
participants of DHS Office of Long Term Living (OLTL) waiver programs who are
18 to 21 years old; and

Dual
eligibles [qualified for both Medicare and Medicaid] age 21 or older whether or
not they need or receive LTSS.

Persons included in the CHC population will be required to
enroll in CHC. However, persons who are eligible for the LIFE program will not
be enrolled into CHC unless they specifically ask to be enrolled.

CHC-MCOs will be accountable for
most Medicaid-covered services, including preventive services, primary and
acute care, LTSS (home and community-based services and nursing facilities),
prescription drugs, and dental services.

Participants who have both Medicaid
and Medicare coverage (dual eligible participants) will have the option to have
their Medicaid and Medicare services coordinated by the same MCO.

The estimated total statewide enrollment of dual eligibles,
older persons, and adults 21 and older with physical disabilities for CHC is
450,000. The CHC population will include individuals with Medicaid-only
coverage who receive or need LTSS, and individuals with full Medicare and
Medicaid coverage (dual eligible), including those with and without LTSS needs.
The CHC population will not include Act 150 program participants, individuals
receiving their services through the lottery-funded Options program, persons
with intellectual/developmental disabilities (ID/DD) who receive services
through the DHS Office of Developmental Programs, or residents of
state-operated nursing facilities, including the State Veterans’ Homes.

This shift to managed care is a work in progress. The state is
actively seeking comments from participants, advocacy organizations, providers,
managed care organizations, care coordination agencies, legislators, family
members, and other interested members of the public. Feedback received will be
used to finalize the program design and issue a Request for Proposals (RFP) in
November 2015.

Follow me on Twitter

Super Lawyers

AVVO

PAELA

About Me

I am a Pennsylvania lawyer with over 35 years experience in estate planning and elder law. I was selected by US News Best Lawyers® as its Lawyer of the Year in Elder Law for 2014 for the Harrisburg, Pennsylvania metropolitan region.
I am of counsel to Marshall, Parker and Weber, a law firm which has offices in Williamsport, Jersey Shore, Wilkes-Barre and Scranton, Pennsylvania. I am past President and a founder of PAELA (the Pennsylvania Association of Elder Law Attorneys). However, the views expressed on this site are my own and not those of PAELA or of Marshall, Parker and Weber.
Most importantly I am a husband, father and grandfather.